NURSING ASSISTANT PROGRAM

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NURSING ASSISTANT PROGRAM

ADMISSION INFORMATION

FOR INFORMATION ABOUT

THE NURSE ASSISTANT PROGRAM

DIANE CHRISTOFFER, RN

OFFICE: 928-681-5660

FAX: 928-718-7084

EMAIL:

dchristoffer@mohave.edu

FOR INFORMATION ABOUT

THE DOCUMENTS REQUIRED

TRACY OWENS, BBA

OFFICE: 928-692-3005

FAX: 928-718-7084

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REV. 05/2015

2 NURSING ASSISTANT PROGRAM PREREQUISITES

Prospective Nursing Assistant students must complete the Nursing Assistant Program

application with all requirements prior to admission.

PREREQUISITES



Appropriate score on assessment test or successful completion of PCS 021.*



CPR Healthcare Provider certification. American Heart Association-Healthcare Provider

or the American Red Cross Professional Rescuer Level. (AHA Heartsaver, ARC Adult, and

ARC Community are not acceptable)

OTHER REQUIREMENTS



Completed and signed application form (attached).



Two Step TB Test: One test less than 12 months prior to clinical rotation period for

semester, and the second less than 6 months prior to clinical rotation period. (Fall

rotations begin in October; spring rotations start in March; summer rotations start in

July.)



Background Check: This must be a Student Check-PreCheck (instructions included) NOT

an Arizona DPS fingerprint card. All students reaching the age of 18 prior to the first day

of clinical rotation.



Pre-Check Recheck authorization required of all applicants reaching the age of 18 prior

to the first day of clinical rotation.



AZ DPS Fingerprint Card may be required by clinical site. Students requiring this card will

be notified by email.



Physical Exam: Both the student and physician copy (attached) are required.



Hepatitis B Vaccinations: Documents of previous vaccinations or declination of vaccine

(form attached).



Vaccination records.



Urine Drug Test will be required, based on clinical requirement. Students requiring this

test for clinical rotation will be notified by email.

*Please Note: If you are a new student at Mohave Community College enrollment paperwork is

required to receive a Student ID number. Once you have a Student ID number, you can make an

appointment with the Testing Coordinator to take the COMPASS Test. Please keep a copy of

your test results; it is reviewed as a part of the Nursing Assistant Program Application.

NURSING ASSISTANT PROGRAM ADMISSION PROCEDURE



The admission and selection process will include COMPASS exam scores and completion

of prerequisites.



The process will not discriminate based on race, color, national origin, gender, religious

background, sexual orientation, age or disability.



Application for the Nursing Assistant Program is in addition to the application for

general admission to MCC.



Student spaces are limited; therefore, students are encouraged to make early

application submissions with all requirements attached.



Application does not guarantee admission to the program. INCOMPLETE applications

will not be considered.

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ALL APPLICATION DEADLINES ARE THREE (3) WEEKS

PRIOR TO THE FIRST DAY OF CLASS.

A completed application packet with the following items should be received in the Nursing

Assistant Office at: Nursing Assistant Program

Mohave Community College

1801 Detroit Avenue

Kingman, AZ 86409

CERTIFICATION

Upon successful completion of this program, the candidate will be eligible to take the Arizona

Nursing Assistant Certification exam which is a credential independent of Mohave Community

College. Board requirements include a list of all states in which the applicant has been

registered as a nursing assistant and certificate number if any; information about any pending

disciplinary action, current investigation or applicant’s current licensure, felony conviction or

conviction of an undesignated or similar offense and the date of absolute discharge of sentence

and unprofessional conduct as defined in the AZBN rules. Any of these matters could affect

your ability to achieve certification and should be addressed prior to the Program start.

If you have any questions or problems, please call the Nursing Assistant Program

Nursing Assistant Program

Mohave Community College

1801 Detroit Ave.

Kingman, AZ 86409

928-757-0820 or

928-681-5660

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2014-2015 Nurse Assistant Application 4

INSTRUCTIONS FOR OBTAINING YOUR BACKGROUND CHECK

FOR A CLINICAL EDUCATION PROGRAM

Mohave Community College-Nursing Assistant Program

Background checks are required on incoming students to insure the safety of the patients treated by students in the clinical education program. You will be required to order your background check in sufficient time for it to be reviewed by the program coordinator or associated hospital prior to starting your clinical rotation. A background check typically takes 3-5 normal business days to complete. The background checks are conducted by PreCheck, Inc., a firm specializing in background checks for healthcare workers. Your order must be placed online through StudentCheck.

Go to www.mystudentcheck.com and select your School and Program from the drop down menus for School and Program. It is important that you select your school worded as Mohave Community College- Nursing Assistant.

Complete all required fields as prompted and hit Continue to enter your payment information. The payment can be made securely online with a credit or debit card. You can also pay by money order, but that will delay the processing of your background check until the money order is received by mail at the PreCheck office. Texas residents will pay $52.50 and New

Mexico residents will pay $52.02. Residents in all other states will pay $49.50 for your records, you will be provided a receipt

and confirmation page of the background check performed through PreCheck, Inc.

PreCheck will not use your information for any purpose other than the services ordered. Your credit will not be investigated, and your name will not be given out to any businesses.

FREQUENTLY ASKED QUESTIONS:

 Does PreCheck need every street address where I have lived over the past 7 years? No. Just the city and state.

 I selected the wrong school, program, or need to correct some other information entered, what do I do? Please email StudentCheck@PreCheck.com, with the details.

 How long does the background check take to complete? Most reports are completed within 3-5 business days.

 Do I get a copy of the background report? Yes, Log into www.mystudentcheck.com and click on “Check Status” and enter your SSN and DOB. If your report is complete, you may click on the application number to download and print a copy. This feature is good for 90 days after submittal. After 90 days, you will be charged $14.95 for a copy of your report, and will need to contact PreCheck directly to request this.

 I have been advised that I am being denied entry into the program because of information on my report and that I should contact PreCheck. Where should I call? Call PreCheck’s Adverse Action Hotline at 800-203-1654. Adverse Action is the procedure established by the Fair Credit Reporting Act that allows you to see the report and to dispute anything reported.

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FULL NAME

Any Other Names Used

Email address: (Provide if you prefer to receive information via email)

Social Security No. /_ / Date of Birth1 _/ _/

Current Address City State Zip

Driver’s License State No.

Have you ever been convicted of a crime?* Yes No

Offense County State Date

*To disclose additional criminal history, please provide those details on a separate sheet of paper and attach it to this form. Please provide all locations where you have resided for the past seven (7) years, starting with your current residence.

City State Dates: From: To:

STATE LAW NOTICES

Minnesota applicants or employees only: You have the right to request in writing from PreCheck, Inc., a complete

and accurate written disclosure of the nature and scope of the report(s) requested by the Company. Place an X here for a disclosure to be sent to you. Oklahoma applicants or employees only: Mark an X here for a free copy of a consumer report if one is obtained by the Company. California applicants or employees only: Please mark this field to receive a copy of an investigative consumer report or consumer credit report at no charge if one is obtained by the Company whenever you have a right to receive such a copy under California law.

California applicants or employees only: By marking an X in the designated field, you will receive and are

acknowledging receipt of the NOTICE REGARDING BACKGROUND INVESTIGATION PURSUANT TO CALIFORNIA LAW.

New York applicants or employees only: If an investigative consumer report has been requested by the Company, the

name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document. You have the right to inspect and receive a copy of the investigative consumer report by directly contacting the consumer reporting agency, PreCheck, Inc. In connection with the Company’s request for the preparation of a consumer report or investigative consumer report about you, the Company has provided you with a copy of Article 23-A of the New York Correction Law. Please mark this field to acknowledge receipt of a copy of Article 23-A: .

Maine applicants or employees only: If you are applying for a position in the State of Maine, you may request and

promptly receive from the consumer reporting agency copies of all investigative consumer reports about you requested by the Company. The name and address of the consumer reporting agency furnishing the report can be found on the following disclosure and authorization document.

Massachusetts applicants or employees only: If you ask, you have the right to a copy of any background check report

concerning you that the Company has ordered. You may contact the Consumer Reporting Agency for a Copy.

Washington State applicants or employees only: You have the right, upon written request made within a reasonable

period of time after your receipt of this disclosure, to receive from the Company a complete and accurate disclosure of the nature and scope of the investigation we requested.

I have read and understand the above information and assert that all information provided by me is true and accurate.

Signature Date

1

The Age Discrimination in Employment Act of 1987 prohibits discrimination on the basis of age with respect to individuals who are at least 40 years of age. This information is necessary for the proper processing of a consumer report.

Nevada Private Investigator License # 1618 Ver. 0913

M

OHAVE

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OMMUNITY

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OLLEGE

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URSING

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ECHECK

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REV. 05/2015

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FULL NAME

Other Names Used

Social Security No. / / Date of Birth / /

Driver’s License State: DL Number:

DISCLOSURE REGARDING BACKGROUND INVESTIGATION

Mohave Community College - Nursing-Recheck (“the Company”) may obtain information about you from a consumer reporting agency made in connection with your clinical privileges as a student. Thus, you may be the subject of a “consumer report” and/or an “investigative consumer report” which may include information about your character, general reputation, personal characteristics, and/or mode of living and which can involve personal interviews. These reports may contain information regarding your credit history, criminal history, social security verification, motor vehicle records (“driving records”), verification of your education or employment history, or other background checks. You have the right, upon written request made within a reasonable time after receipt of this notice, to request disclosure of the nature and scope of any investigative consumer report.

Please be advised that the nature and scope of the most common form of investigative consumer report obtained with regard to applicants for employment is an investigation into your education and/or employment history conducted by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888)PreCheck [1-888- 773-2432] or another outside organization. The scope of this notice and authorization is

all-encompassing, however, allowing the Company to obtain from any outside organization all manner of consumer reports and investigative consumer reports now and throughout the course of your clinical privileges as a student to the extent permitted by law.

I understand the information obtained will be used as one basis for extension or denial of clinical privileges. I hereby give permission to PreCheck Inc. to disclose the contents of the report to my school program and any healthcare facility I come into contact with as part of my clinical education.

ACKNOWLEDGMENT AND AUTHORIZATION

I acknowledge receipt of the DISCLOSURE REGARDING BACKGROUND INVESTIGATION and A

SUMMARY OF YOUR RIGHTS UNDER THE FAIR CREDIT REPORTING ACT and certify that I have read and understand both of those documents. I hereby authorize the obtaining of “consumer reports” and/or “investigative consumer reports” by the Company at any time after receipt of this authorization and

throughout the term of my employment, contract or clinical privileges as a student, if applicable. To this end, I hereby authorize, without reservation, any law enforcement agency, administrator, state or federal agency, institution, school or university (public or private), information service bureau, employer, or

insurance company to furnish any and all background information requested by PreCheck, Inc., 3453 Las Palomas Rd. Alamogordo, NM 88310; 1(888) PreCheck [1- 888-773-2432] another outside organization acting on behalf of the Company, and/or the Company itself. I agree that a facsimile (“fax”), electronic or photographic copy of this Authorization shall be as valid as the original.

By signing below, I confirm that I have read and understand the above information and that I provide my consent.

Signature Date

Nevada Private Investigator License # 1618 Ver . 0913 www.PreCheck.com info@precheck.com Ph: 800-999-9861 Fax: (800) 207-2778

M

OHAVE

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OMMUNITY

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OLLEGE

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URSING

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NURSING ASSISTANT PROGRAM

Student Application Form

All qualified applicants are considered for admission, and students are treated without regard to race, color,

religion, sex, national origin, age, or marital status. Information related to these areas will be used for

statistical analysis and not as criteria for admission to the nursing program. All information will be kept

confidential.

AREA OF INTEREST

Please Select from the Following Location you wish to be considered for:

☐ Kingman Campus

☐ Lake Havasu City Campus ☐ Bullhead City Campus ☐ North Mohave Campus

Please Specify the Semester You wish to attend:

☐

FALL

☐

SPRING

☐

SUMMER

☐

ACCELERATED (IF OFFERED)

APPLICANT INFORMATION

Date:

Social Security #:

MCC ID#:

(REQUIRED)

Full Name:

(Last) (First) (Middle)

Mailing Address:

(Street)

(City) (State) (Zip)

Home Phone:

Cell Phone:

Email Address:

Gender, Birth Date, Marital Status, and Ethnicity/Race

Responses to Gender, Marital Status, and Ethnicity/Race, Birth Date and Special Population will be kept confidential and is

for statistical purposes only.

Gender: Male Female

Birth Date:

If still in High School, Grade Level

(REQUIRED) Month Day Year

_{☐ 11}

th

_{☐ 12}

th

Marital Status:

☐

Single

☐

Married

☐

Divorced

☐

Widowed

High School:

Maiden Name:

Other Name(s) Used:

Ethnicity/Race

American Indian or Alaskan Native

Asian or Pacific Islander

Hispanic

Black/Non-Hispanic

White/Non-Hispanic

Other/Unknown

Special Population Questions

☐

NO-No Special Population

☐

EC- Economically Disadvantaged

Individuals- eligible for: AFDC or other

Public Assistance.

☐

HA- Individuals with

Disabilities- handicap as

defined by the Americans

with Disabilities Act.

☐

LE- Individuals with Limited English

Proficiency

☐

SP-Single Parents- has custody and

support/care of dependent child(ren)

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REV. 05/2015

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HEALTH REQUIREMENTS: (Dates when completed)

TB: (copy) _{CXR: (copy)} Hep B: (copy) Or

decline: CPR: (copy)

Precheck:

(copy) Physical: (copy) COMPASS SCORES: Reading Writing Math

PCS 021 COMPLETED

PCS 022 COMPLETED

PCS 023 COMPLETED

Inventory Skills Sheet:

Workbook % Grade Completed:

FINAL GRADE:

Disclaimer and Signature

 I understand that if accepted into the Nursing Assistant Program, I will be required to travel for clinical

experiences, and that I will be responsible for my own transportation and meals.

 I understand that if accepted, I will be required to meet the health requirements of the Nursing Assistant Program.

 I understand Mohave Community College presents certain courses, labs or workshops required as a part of the Nursing Assistant Certificate Program in collaboration with diverse public and private health organizations, including health agencies, hospitals and clinics. Those collaborating organizations permit the College to conduct such courses within each organization’s facilities, but require that all participants, whether instructors or students, furnish qualifying health records and information, including (but not limited to) immunizations, titer results, the individual’s contagious disease history and a copy of a valid CPR card. The collaborating organizations established health requirements may vary in light of different circumstances.

 I understand the above statement, and hereby authorize Mohave Community College to release any of my medical records and information in their possession to such organizations, for the purpose of qualifying me to participate in such instructional courses, labs or workshops.



I hereby certify that the facts set forth in this Student Application are true and complete to the best of my knowledge. I understand that if accepted into the Nursing Assistant Program, any falsified statements on this application shall be considered cause for suspension or dismissal.

Signature:

Date:

Mail COMPLETED Application To:

Nursing Assistant Program Mohave Community College

1801 Detroit Avenue Kingman, AZ 86409

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Nursing Assistant Student

PHYSICAL EXAMINATION FORM

“

STUDENT USE ONLY”

(Student must complete this side)

Student Name:

Social Security #:

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Nursing Assistant Student Functions

A Nursing Assistant Student MUST be able to perform functions as sampled below. This not an ALL INCLUSIVE list,

1. Stand and walk continuously for up to eight hours.

2. Visual acuity and depth perception to read healthcare information.

3. Hearing acuity and to hear machine alarms, announcements on PA systems, normal conversations, and through

stethoscopes.

4. Safely handle blood and other body excretions and secretions.

5. Perform basic resuscitation and emergency procedures according to CPR protocols.

6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care, up to 300 pounds

with assistance.

7. Ability to lift 50 pounds.

8. Lift, move, and operate equipment used in the care of patients.

9. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders.

10. Psychological stability to perform effectively under stress.

11. Ability to exercise critical thinking, reasoning and judgment in a client care situation.

Understanding of Requirements

As a Nursing Assistant Student of MCC, I understand that I must provide the following requirements:

1) Proof of current Negative TB (2-step) or Chest X-ray

2) Current CPR certification (Heartsaver, Adult or Community CPR is not acceptable)

3) HBV vaccination declination statement or proof of vaccination series

4) Current Physical Examination provided by a physician found on the back of this form

5) Drug screen results if asked. (If a positive result is received the drug order must be verified with proof of

prescription.)

As a Nursing Assistant Student of MCC, I understand that failure to provide CURRENT documentation will result in

dismissal from the nursing assistant program. I further understand I must be able to meet the physical functions of a

nursing assistant, such as the sampling above indicates. I have read and understand the requirements, functions, and I

am able to perform all the above listed functions.

Student Name (please print):

Date:

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2014-2015 Nurse Assistant Application 10

“PHYSICIAN USE ONLY”

(Physician must complete this side)

STUDENT NAME:

HEENT:

Lungs:

Heart:

Abdomen:

Vital Signs:

Extremities/Joints:

Neurological/Mental:

VISION: (R)

(L)

CORRECTED:

(R)

(L)

Please list all prescription medications being used by the student and the reason:

Please list all chronic conditions or medical problems the student has:

Record of Two-Step TB Tests

Clinical facilities utilized for MCC Nursing Assistant Student Clinical Experiences require proof of TB tests. Students will

only be allowed an exception based on a medical condition and a physician’s note is required.

TEST NUMBER:

ADMINSTER DATE:

READ DATE:

RESULTS:

READ BY:

1

2 NEGATIVE X-RAY:

Report must reflect: “X-ray conducted to rule out TB in patient.”

Nursing Assistant Student Functions

Upon appropriate training, the Nursing Assistant Student MUST be able to perform functions as sampled below. This

not an ALL INCLUSIVE list,

1. Stand and walk continuously for up to eight hours.

2. Visual acuity and depth perception to read healthcare information.

3. Hearing acuity and to hear machine alarms, announcements on PA systems, normal conversations, and through

stethoscopes.

4. Safely handle blood and other body excretions and secretions.

5. Perform basic resuscitation and emergency procedures according to CPR protocols.

6. Lift, move, position, and otherwise handle patients to minimize discomfort and provide basic care, up to 300

pounds with assistance.

7. Ability to lift 50 pounds.

8. Lift, move, and operate equipment used in the care of patients.

9. Manual dexterity to manipulate syringes, vials, pills, buckle and unbuckle, apply dressings and binders.

10. Psychological stability to perform effectively under stress.

11. Ability to exercise critical thinking, reasoning and judgment in a client care situation.

Physicians Signature of Authorization

Based on this physical examination, do you find this person capable of performing these types of functions.

without ANY reservations?

YES:

NO:

(If No, Please Explain):

Physician Name (please print):

Date:

Physician Signature:

Telephone:

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NURSING ASSISTANT HEPATITIS B FORM

IMPORTANT INFORMATION

Hepatitis B is a viral infection caused by Hepatitis B virus (HBV). Individuals who work in health care settings are at more risk than others for acquiring this infection. Because of this increased risk, it is recommended that the nursing assistant student receive the Recombivax HB vaccine as a protective measure. A high percentage (85-95%) of healthy people who receive two doses of the vaccine and a later booster achieve high levels of antibody development (anti-HBV) and receive protection against Hepatitis B. Full immunization requires three doses of vaccine over a six month period. The duration of immunity, while believed to be life-long, is unknown at this time. The incidence of side effects is low; however, it is not known whether the Recombivax HB vaccine can cause fetal harm when administered to pregnant women; therefore, the Recombivax HB vaccine should not be given to pregnant women.

You may obtain the Recombivax HB vaccine series from your physician, the Department of Health Services, or the Occupational Health Clinic at your local hospital. The choice of receiving the Hepatitis vaccine is yours. You must; however, fill in the applicable information below and return as indicated